Health System Barriers for HPV-vaccine uptake in females with a Turkish or Moroccan Migration background in the Netherlands

Abstract Background HPV vaccine uptake in female adolescents with a Turkish or Moroccan migration background in the Netherlands is lower as compared to the national average. This study aimed to study health system barriers for HPV vaccine uptake in these groups. Methods Semi-structured interviews with Turkish/Moroccan (2nd and 3rd degree migrants) female adolescents (12-18 years old), their parents and grandparents were conducted. In addition a focus group discussion with healthcare providers with particular experience with HPV immunization and the target groups was organized. Data was collected between November 2021-April 2022. Results 22 interviews were conducted among twenty-three individual participants. Sixteen participants with a Turkish migration background were recruited and seven participants were having a Moroccan migration background. In thirteen cases young women in the families did not receive an HPV vaccination. Health system barriers identified were: language barriers in the information provided, focus on HPV being a sexually transmitted disease in information campaigns, lack of knowledge and awareness on HPV among participants and healthcare providers and inability to reach the target groups with tailored immunization programs. Similar health system barriers were mentioned by the healthcare providers, but also included a lack of trust in the government and healthcare institutions, insufficient coordination and collaboration between different healthcare providers. National immunization programs with mass campaign vaccination is mentioned as a barrier to reach families with a Turkish/Moroccan migration background. Conclusions Various health system barriers were addressed to be related to HPV vaccine uptake in females with a Turkish/Moroccan migration background in the Netherlands. Despite similarities concerning health system barriers among community members and healthcare providers, different health system barriers were also mentioned.

The literature highlights low vaccination coverage among most minority or ethnic pediatric communities in EU, including migrants. In addition to being less likely to get a vaccine, such communities may be vulnerable to developing certain infectious diseases. It is particularly important in the context of the current humanitarian crisis connected with Russia's aggression towards Ukraine. Identification of potential barriers to vaccination and system gaps is crucial to further ensure that underserved pediatric communities benefit from the same level of protection as the general population in terms of disease prevention and control, including those diseases which can be prevented by routine vaccinations. The proposed workshop moderated by well-known experts of the subject (Bernardette Kumar and Maria Ganczak) will be based on the results from qualitative data collected as a part of the 5-year RIVER-EU (Reducing Inequalities in Vaccine uptake in the European region -Engaging Underserved communities) project which tackles health system barriers among selected underserved communities living in four countries: Ukrainian migrants in Poland, females with a Turkish and Moroccan migration background in the Netherlands, marginalized Roma communities in Slovakia and migrants/refugees in Greece. This interactive workshop will provide short (5 minutes per country) comparisons of the health system barriers to vaccination against MMR (measles, mumps, rubella) and Human Papillomavirus (HPV) in children living in different underserved communities, and contrast barriers to vaccination experienced by the community members with barriers perceived by the health care professionals. International comparisons of in-depth information collected during qualitative studies (interviews and focus groups) will help to provide an increased understanding of the health system determinants of low vaccine uptake in their specific multifactorial contexts that will vary in terms of geography, size, wealth, health sector structures, culture and vaccination law. Such qualitative research is particularly valuable regarding its potential for producing comprehensive and refinement analyses adjusted for understanding the voices of underserved communities. The session will go beyond describing those. Based on the presentations the participants will be divided into 4 groups to discuss (15 minutes) the Key Barriers; Key Facilitators to vaccination; Main lessons Learnt; Ways forward for the future to increase vaccine uptake among underserved pediatric communities to reduce the burden of vaccine preventable diseases. These 4 groups of workshop participants will be led by experts from the MEMH and IDC sections. Then, concluding remarks will be presented by each group (5 minutes per group). The final resume delivered by session chairs will end the workshop. Key messages: The health system barriers to child vaccination among underserved communities vary among European countries, and the optimal way to adequately address them is likely to be context specific.
The RIVER-EU project gives an opportunity to discuss lessons already learnt around the different components of the vaccination process and to pinpoint ways forward for the future to reduce the VPD.
Background: HPV vaccine uptake in female adolescents with a Turkish or Moroccan migration background in the Netherlands is lower as compared to the national average. This study aimed to study health system barriers for HPV vaccine uptake in these groups.

Methods:
Semi-structured interviews with Turkish/Moroccan (2nd and 3rd degree migrants) female adolescents (12-18 years old), their parents and grandparents were conducted. In addition a focus group discussion with healthcare providers with particular experience with HPV immunization and the target groups was organized. Data was collected between November 2021-April 2022.
Results: 22 interviews were conducted among twenty-three individual participants. Sixteen participants with a Turkish migration background were recruited and seven participants were having a Moroccan migration background. In thirteen cases young women in the families did not receive an HPV vaccination.
Health system barriers identified were: language barriers in the information provided, focus on HPV being a sexually transmitted disease in information campaigns, lack of knowledge and awareness on HPV among participants and healthcare providers and inability to reach the target groups with tailored immunization programs. Similar health system barriers were mentioned by the healthcare providers, but also included a lack of trust in the government and healthcare institutions, insufficient coordination and collaboration between different healthcare providers. National immunization programs with mass campaign vaccination is mentioned as a barrier to reach families with a Turkish/ Moroccan migration background. Conclusions: Various health system barriers were addressed to be related to HPV vaccine uptake in females with a Turkish/Moroccan migration background in the Netherlands. Despite similarities concerning health system barriers among community members and healthcare providers, different health system barriers were also mentioned.

Background:
Before Russia's aggression, Ukrainians were the largest migrant group in Poland. However, data on health system barriers to vaccination in this vulnerable group were not collected. The study aimed to explore barriers to child MMR/HPV vaccination and related access to Polish healthcare services.

Methods:
Between December 2021-January 2022, a qualitative study of Ukrainian migrants (UM) living in Poland, recruited through a snowball sampling method, was conducted as a part of RIVER-EU project. 8 focus groups were held with 49 UM aged 16-44 years, followed by interviews with 12 health care providers (HCP).

Results:
UM and HCP experienced communication barriers despite language similarities. HCP reported that since a UM is not willing to register at a GP practice he cannot be reached by the Polish vaccination system. UM experienced challenges in navigating the system and accessing credible information in Ukrainian, no official local health authority vaccination material existed either. UM complained that there are no translated versions of vaccination materials accessible at the PHC facilities and they are not adequately informed about the possible side effects of vaccines; HCP reported the lack of time provided by the system for health promotion. UM were not familiar and rather hesitant regarding self-paid vaccines, such as HPV vaccine. In Poland and Ukraine this topic is not targeted at school curriculum neither by information campaigns. UM reported that HPV vaccine is not of interest for them due to the high cost, however they might consider it for their daughters, if the cost was fully refunded.

Conclusions:
The study identified main health system barriers to child vaccination regarding economic UM in Poland, seen from the perspective of migrants and HCP and pinpointed issues for improvement. This can serve as a starting point to confront vaccination related challenges in the context of Ukrainian refugee crisis Poland is currently dealing with.

Background:
People from marginalized Roma communities often experience poverty, limited access to education, employment, housing, and health care (HC). The aim of the study was to explore the perceptions of people from marginalized Roma communities and health professionals regarding health system (HS) barriers to HPV vaccination.

Methods:
A qualitative study was conducted in the Kosice region as a part of the RIVER-EU project. Semi-structured interviews with marginalized Roma parents (N = 18), children (N = 15), and health professionals (N = 18) were audio-recorded and thematic analysis of the transcripts was performed in MAXQDA.

Findings:
Four main themes were identified regarding HS barriers: 1. Lack of information (lack of culturally and linguistically appropriate information, lack of information provision from HC providers, unreliable and conflicting information on the internet), 2. Restricted access to HC providers (lack of capacities, work overload, long wait in the waiting room, distance, traffic connection), 3. Financial and organizational barriers (limited coverage of vaccination expenses from health insurance, picking up prescribed vaccines in a pharmacy by parents, parental consent), 4. Attitudes and behaviours of HC providers (neglect of care, double standard, inappropriate behaviour and communication, prejudices, racism).

Conclusions:
The reasoning and perception of several barriers to HPV vaccination differ among groups of respondents. Nevertheless, HPV is not viewed as a priority by both -marginalized Roma and health professionals. HS fails to reach marginalized Roma with appropriate information about HPV and HPV vaccination. Moreover, the lack of capacities and motivation of HC providers to address these topics lead to a lack of awareness. Organization and health insurance coverage of vaccination pose additional barriers to HPV vaccination.

Methods:
A qualitative study was conducted in the wider Athens area as part of the RIVER-EU project. Four Focus Groups and 23 semi-structured interviews were conducted with health care professionals, children and parents with a migrant background. Data were analysed using thematic content analysis. Findings: Identified barriers relate to the lack of standard operational procedures at system level that would define a schedule of vaccinations for migrants. Migrant vaccinations are subject to availability of vaccines (MMR as opposed to HPV) and potential threat of outbreaks (MMR vs HPV). There